Case report: surgical total cardiac denervation for refractory vasospastic angina: first report with pre- and post-operative autonomic assessment

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  Figure 1. MIBG parameters. MIBG, metaiodobenzylguanidine; ROI, regions of interest; H, heart; M, mediastinum. The late heart-to-mediastinum (H/M) ratio reflects cardiac sympathetic innervation. Higher values indicate preserved sympathetic nerve activity, whereas markedly reduced values indicate impaired or absent sympathetic innervation. Reference values depend on imaging methodology; in this case, the pre-operative H/M ratio of 2.55 was consistent with preserved sympathetic innervation, while the post-operative value of 0.82 indicated severe sympathetic denervation.

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  Figure 2. Coronary angiography with acetylcholine provocation testing. A: Baseline coronary angiography demonstrating a normal left anterior descending artery (LAD). B: Following intracoronary administration of 100 μg acetylcholine, diffuse severe (>90%) epicardial LAD vasospasm developed and reproduction of the patient's typical anginal symptoms. C: Complete angiographic resolution after intracoronary nitroglycerin administration.

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  Figure 3. Surgical total cardiac denervation procedure. (A) Isolator® Synergy™ Clamp. (B) The distal ascending aorta is circumferentially treated with RF energy using the Isolator® Synergy™ Clamp (AtriCure Inc.), creating a continuous transmural lesion of at least 1 cm in width to minimize the potential for sympathetic nerve regrowth. (C) A cut-and-sew transection of the ascending aorta and the central pulmonary artery with the distal lesion set below the aortic cross clamp.

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  Figure 4. Surgical total cardiac denervation procedure. (A) EnCompass® Synergy™ Clamp. (B) the use of the EnCompass® Synergy™ Clamp (AtriCure Inc.) as depicted by AtriCure Inc. (C) A left atrial box lesion isolating the dorsal left atrium and pulmonary veins was created using the EnCompass® Synergy™ Clamp (AtriCure Inc.), targeting autonomic fibres entering posteriorly. To achieve a complete box lesion, the clamp was applied from both the left and right sides of the heart.